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Authors: Emily V. Wechsler, Walter Chan, Eric D. Shah
Journal: Clinical Gastroenterology and Hepatology (2023)

We thank Dr Ford and Dr Howden for their interest and important response toward achieving shared understanding in the context of our health economic study on management strategies for uninvestigated dyspepsia.1Ford A.C. et al.Clin Gastroenterol Hepatol. 2023; 21: 2986-2987Abstract Full Text Full Text PDF Scopus (1) Google Scholar,2Wechsler E.V. et al.Clin Gastroenterol Hepatol. 2023; 21: 2378-2388.e28Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Cost-effectiveness/cost-satisfaction analyses provide a different lens than a network meta-analysis on the same underlying clinical evidence. The network meta-analysis study design defines long-standing guidelines that strongly recommend against routine upper endoscopy for uninvestigated dyspepsia in all low-risk patients.3Moayyedi et al.Am J Gastroenterol. 2017; 112: 988-1013Crossref PubMed Scopus (367) Google Scholar Yet, gastroenterologists continue to consider endoscopy for these patients. The cost-effectiveness/cost-satisfaction study design can ask: what factors yield real-world differences between guidelines and practice?4Shah E.D. et al.Am J Gastroenterol. 2021; 116: 748-757Crossref PubMed Scopus (16) Google Scholar, 5Shah E.D. et al.Clin Gastroenterol Hepatol. 2022; 20: 136-144.e31Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 6Shah E.D. et al.MDM Policy Pract. 2021; 62381468320978417PubMed Google Scholar In our primary analysis, we used aggregate individual data reported in Supplementary Figure 1 of Eusebi et al7Eusebi L.H. et al.BMJ. 2019; 367: l6483Crossref PubMed Scopus (38) Google Scholar to facilitate extensive sensitivity analyses on patient-level data. We also performed 2 additional sensitivity analyses to accommodate primary relative risk estimates for treatment nonresponse, likelihood of undergoing endoscopy, and treatment satisfaction informed directly by their network meta-analysis from an insurer perspective. If we assume that health care seeking is driven by clinical nonresponse alone, then management preference depends on relative risks of clinical nonresponse for prompt endoscopy and test-and-treat strategies, which were similar according to Eusebi et al.7Eusebi L.H. et al.BMJ. 2019; 367: l6483Crossref PubMed Scopus (38) Google Scholar If dissatisfaction is assumed to drive health care seeking,8Koloski N.A. et al.Aliment Pharmacol Ther. 2003; 17: 841-851Crossref PubMed Scopus (119) Google Scholar then prompt endoscopy would be the preferred strategy when performed routinely for all patients. Although only 6 of 15 clinical trials reported patient satisfaction outcomes, they included more than 2800 enrolled patients in the rigorous network meta-analysis by Eusebi et al.7Eusebi L.H. et al.BMJ. 2019; 367: l6483Crossref PubMed Scopus (38) Google Scholar The impetus for our study is that we share the strong sentiment advocating long-standing guidelines that recommend against routine, up-front endoscopy for all patients. Yet, real-world practice continues to diverge strikingly from guidelines. Our findings align with observations that providers might consider a 1-time, up-front endoscopy on a case-by-case basis beyond clinical factors alone, often assuming that a normal 1-time upper endoscopy would help engage a conversation to rapidly transition subsequent care toward education and treatment while minimizing further testing.9Drossman D.A. et al.Gastroenterology. 2021; 161: 1670-1688.e7Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar,10Drossman D.A. et al.Clin Gastroenterol Hepatol. 2020; 18: 1417-1426Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Face validity for this openness to endoscopy is apparent from at least 2 factors. First, insurers in the United States already reimburse for index endoscopies performed for uninvestigated dyspepsia despite guidelines, and it should be less than plausible for an insurer to willingly spend money without realizing cost savings. Second, even gastroenterologists taking part in closely monitored clinical trial settings frequently performed upper endoscopies for patients classified as low risk, exceeding 20% of patients assigned to noninvasive management arms. In other words, clinical trials that support the test-and-treat strategy also reflect real-world flexibility. In the end, many patients end up receiving 1 or more endoscopies, so shared efforts to identify effective alternatives to the second or third endoscopy also may be effective in achieving high value management of dyspepsia. The authors would like to acknowledge our co-authors of the original article: Nitin K. Ahuja, MD, MS (Penn Medicine, Philadelphia, PA); Darren Brenner, MD (Northwestern Medicine, Chicago, IL); Lin Chang, MD (University of California Los Angeles, Los Angeles, CA); William D. Chey, MD (Michigan Medicine, Ann Arbor, MI); Anthony J. Lembo, MD (Cleveland Clinic Foundation, Cleveland, OH); Baha Moshiree, MD, MSCI (Atrium Health, Charlotte, NC); Judy Nee, MD (Beth Israel Deaconess Medical Center, Boston, MA); Shailja C. Shah, MD, MPH (University of California San Diego, San Diego, CA); and Kyle Staller, MD, MPH (Massachusetts General Hospital, Boston, MA). Relative Cost-effectiveness of Management Strategies for Uninvestigated DyspepsiaClinical Gastroenterology and HepatologyVol. 21Issue 11PreviewWe read the article by Wechsler et al.1 The authors constructed a health economic model dealing with the initial management of uninvestigated dyspepsia. This issue has occupied clinical trialists and evidence synthesis experts for the last 30 years. Overwhelming evidence points to noninvasive strategies, such as testing for Helicobacter pylori and treating individuals testing positive with eradication therapy (so-called "test and treat") or empirical acid suppression, being the most cost-effective, compared with prompt endoscopy. Full-Text PDF